Smith Benjamin, Genuardi Michael V, Koczo Agnes, Zou Richard H, Thoma Floyd W, Handen Adam, Craig Ethan, Hogan Caroline M, Girard Timothy, Althouse Andrew D, Chan Stephen Y
1 Department of Medicine, University of Pittsburgh, USA.
2 Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, and Blood Vascular Medicine Institute, Division of Cardiology, Department of Medicine, University of Pittsburgh Medical Center, USA.
Pulm Circ. 2018 Jul-Sep;8(3):2045894018790316. doi: 10.1177/2045894018790316. Epub 2018 Jul 3.
Pulmonary arterial hypertension (PAH) is a deadly vascular disease, characterized by increased pulmonary arterial pressures and right heart failure. Considering prior non-US studies of atrial arrhythmias in PAH, this retrospective, regional multi-center US study sought to define more completely the risk factors and impact of paroxysmal and non-paroxysmal forms of atrial fibrillation and flutter (AF/AFL) on mortality in this disease. We identified patients seen between 2010 and 2014 at UPMC (Pittsburgh) hospitals with hemodynamic and clinical criteria for PAH or chronic thromboembolic pulmonary hypertension (CTEPH) and determined those meeting electrocardiographic criteria for AF/AFL. We used Cox proportional hazards regression with time-varying covariates to analyze the association between AF/AFL occurrence and survival with adjustments for potential cofounders and hemodynamic severity. Of 297 patients with PAH/CTEPH, 79 (26.5%) suffered from AF/AFL at some point. AF/AFL was first identified after PAH diagnosis in 42 (53.2%), identified prior to PAH diagnosis in 27 (34.2%), and had unclear timing in the remainder. AF/AFL patients were older, more often male, had lower left ventricular ejection fractions, and greater left atrial volume indices and right atrial areas than patients without AF/AFL. AF/AFL (whether diagnosed before or after PAH) was associated with a 3.81-fold increase in the hazard of death (95% CI 2.64-5.52, p < 0.001). This finding was consistent with multivariable adjustment of hemodynamic, cardiac structural, and heart rate indices as well as in sensitivity analyses of patients with paroxysmal versus non-paroxysmal arrhythmias. In these PAH/CTEPH patients, presence of AF/AFL significantly increased mortality risk. Mortality remained elevated in the absence of a high burden of uncontrolled or persistent arrhythmias, thus suggesting additional etiologies beyond rapid heart rate as an explanation. Future studies are warranted to confirm this observation and interrogate whether other therapies beyond rate and rhythm control are necessary to mitigate this risk.
肺动脉高压（PAH）是一种致命的血管疾病，其特征为肺动脉压力升高和右心衰竭。考虑到此前美国以外地区关于PAH患者房性心律失常的研究，这项回顾性、区域性多中心美国研究旨在更全面地确定阵发性和非阵发性心房颤动及心房扑动（AF/AFL）的危险因素及其对该疾病死亡率的影响。我们确定了2010年至2014年间在匹兹堡大学医学中心（UPMC）医院就诊、符合PAH或慢性血栓栓塞性肺动脉高压（CTEPH）血流动力学和临床标准的患者，并确定了那些符合AF/AFL心电图标准的患者。我们使用Cox比例风险回归模型与时变协变量分析AF/AFL发生与生存之间的关联，并对潜在混杂因素和血流动力学严重程度进行了调整。在297例PAH/CTEPH患者中，79例（26.5%）在某个时间点患有AF/AFL。AF/AFL在PAH诊断后首次被发现的有42例（53.2%），在PAH诊断前被发现的有27例（34.2%），其余患者的发病时间不明。与没有AF/AFL的患者相比，AF/AFL患者年龄更大，男性更常见，左心室射血分数更低，左心房容积指数和右心房面积更大。AF/AFL（无论在PAH之前还是之后诊断）与死亡风险增加3.81倍相关（95%CI 2.64 - 5.52，p < 0.001）。这一发现与血流动力学、心脏结构和心率指数的多变量调整一致，也与阵发性与非阵发性心律失常患者的敏感性分析结果一致。在这些PAH/CTEPH患者中，AF/AFL的存在显著增加了死亡风险。在没有高负荷未控制或持续性心律失常的情况下，死亡率仍然升高，因此提示除心率过快之外还有其他病因。有必要开展进一步研究来证实这一观察结果，并探讨除心率和节律控制之外是否需要其他治疗来降低这种风险。
